Working in an inpatient rehab facility (IRF) with people who have sustained a traumatic brain injury, can pose a set of unique challenges. The goal for most patients in an IRF is to return home, and just as importantly, return to their community.
It’s important as clinicians that we know what our patients with traumatic brain injury considers their ‘community.’ Community is different for all of us. There is no ‘one size fits all’ approach to assisting a patient and their families with community re-integration. Patients with traumatic brain injury not only have the physical challenges that accompany such an injury, but they also have cognitive and behavioral challenges, making community re-integration an uphill battle. As clinicians- it’s part of our job to try to consider the barriers that our clients face- and help problem-solve!
How do I know what the patient considers their ‘community’?
Just ask! Asking your patient and their loved ones what their therapy goals are is just as important as compiling your assessment and formulating your plan of care. As clinicians, we can sometimes mistakenly think that ‘we know best’. This may be partially true- (all that schooling and clinical experience did teach us something!) But it’s imperative that we get input from the patient as to what they want to accomplish! Gaining insight into their world is the most powerful information we could hope to get. You also need to establish trust with your patient. This way, they’ll collaborate with you on these goals, and be guided by the expertise you bring to the table.
How does community re-integration for Traumatic Brain Injury look when things are ‘normal?’
Community re-integration for patients with traumatic brain injury is different for each and every person. Under non COVID-19 restrictions, I typically plan an outing in the middle-to-end of the patient’s rehabilitation stay. The therapist will accompany one patient, or group of patients, to a pre-selected location that has significance and functionality. In an ideal world, the patient’s family or caregiver would also attend the outing so they can see what type of challenges the patient may face with community re-integration. The therapist might guide the patient through an activity (collecting items from a shopping list, money management, ordering food for communication practice, etc). On returning to the IRF, the therapist, family/caregiver, and the patient will discuss the outing – what went well, and what was challenging.
Community outings really are wonderful opportunities for the family/caregiver to see in real time how challenging re-integration can be. Sometimes, people might not really believe the therapist when we attempt to educate regarding how challenging navigating the community can be. It can be a very abstract concept (especially for the person with the traumatic brain injury). By including it in your care plan, it can be an opportunity for the patient to ‘safely fail’. The person, and their family, can then problem solve with guidance from their therapist.
But how do I work on community re-integration during the COVID-19 pandemic, when we can’t leave the hospital?!
Without a doubt, this is a challenging time- for all of us! However, expecting our patients to stay home, and not engage with the community is unrealistic. I designed the following tips to help you, the clinician, learn how to make community re-integration a part of your plan of care in these unprecedented times of COVID-19, for your patients with traumatic brain injury.
1. Know what community means to the patient and the family
This seems like a foregone conclusion, but it’s surprising how often clinicians simply don’t ask the patient what they want to be able to do outside of walking and ADLs. Understanding what the patient determines to be community re-integration, and where they want to be able to go will help drive your treatment and make realistic plans. Reserve all judgment – just because it’s not something you would do, doesn’t make it wrong. Early education with patients and their families is key, especially now when the rules of navigating the community are rapidly changing.
If you’re not sure about where to start here, check out the Community Integration Questionnaire! It was designed to assess levels of community integration for people with TBI, and might be a good kicking off point for discussion with your patient.
2. Review the ‘new normal’
Make your patient a memory book (or use a planner – their choice) with more than just the standard calendar, names of therapists, and basic information about the IRF they’re rehabbing in. Add a page with bullet points about mask wearing, hand hygiene, and what social distancing is – even add pictures to illustrate the appropriate way to wear a mask, and what social distancing floor markers look like in their favorite store. Be creative and think outside of your normal therapy box! If the patient needs some type of communication board or device, be sure to add mask wearing and social distancing as options.
For a great, evidenced based reference for memory books (and cognitive therapy), check out the American Congress of Rehabilitation Medicine (ACRM)’s Cognitive Rehabilitation Manual. The manual costs around $125 for non-members, and is a really valuable tool to help ‘level up’ your clinical practice when it comes to cognitive rehabilitation.
3. Integrate technology
As a disclaimer, this isn’t going to be feasible for some patients! Limited access to technology, decreased cognitive status, or just not being receptive to using it… technology has inherent issues. That being said, include use of technology into your sessions (if the patient is agreeable) whenever you can! Most grocery and department stores are offering shop from home, curbside pick-up, and delivery at this time. This may be the first time your patient (and their families) may be utilizing a service like this! Breaking the process into smaller steps, and making a written list (that you can place in their memory book) will help the patient to continue participating in shopping, without becoming overwhelmed by a completely new process.
Show your patients and their families how to utilize services such a Zoom, Skype, and GoogleDuo to decrease the feeling of social isolation during this time. Again, breaking the process into smaller, manageable steps and placing a written copy in a memory book or planner will be helpful for recall.
4. Use the Multiple Errands Test in your facility
The Multiple Errands Test (MET) measures how impairments in executive performance affect functioning in natural contexts. This is best described as a ‘scavenger’ hunt in your IRF. Many editions of the MET exist, but it may be best to modify a version of it for your facility. This may then be referred to as a Modified Multiple Errands Test (MMET). The MMET is a great way for your patients to practice multi-tasking, challenge their divided attention, and attempt to demonstrate appropriate social skills in a safe and controlled environment. It can be done ambulating, with or without a device, and can be completed at the wheelchair level as well. This is a great opportunity to practice wearing a mask while moving, and knowing the true definition of social distancing. Check out the MET right here!
5. Plan…plan…plan!
Do you know that your patient is going to be going into the community soon after discharge? Assist them and their caregivers/families with making a plan for what their outings could look like. Stress the importance of having a concrete plan for when they arrive. Maybe, you can even suggest the family scope out the location (or do some googling) ahead of time. Identify where the bathrooms are located, figure out where the scooters and customer service are located, etc. Knowing these things before they get to their location can decrease anxiety about navigating the area and increase confidence.
Be sure to review any type of behavioral management strategies that were effective while the patient was in the IRF. It’s critically important that families and caregivers are aware of the patient’s behavioral triggers, and methods for de-escalation. Cognitive impairment and behavioral challenges are the top-ranked stressors for caregivers when a patient with a traumatic brain injury is discharged home. We should strive to ensure families and caregivers feel just as prepared and supported as the patient does, on discharge.
So… now what?
In an ideal world, we would be able to take our patients on a community outing prior to discharge ourselves. We could help them navigate, problem solve, and then review the experience once arriving back at the hospital. We could support and educate their families and caregivers and provide feedback in real time. Unfortunately, in the ever-changing world of COVID-19, this isn’t possible for most clinicians and patients right now. We need to be outside the box thinkers and get creative with assisting our patients with community reintegration. Don’t be intimidated by the current situation! Look at it as an opportunity to challenge yourself as a clinician and evolve your treatment interventions. You can do it! It just takes a little more time and critical thinking.
For more information on how you can better support people living with traumatic brain injury, visit www.biausa.org. It has great resources on community re-integration for clinicians, people with BI, and their loved ones.
Want to ‘level up’ your skills as a clinician working with traumatic brain injury? Check out our Certified Brain Injury Specialization Training page for information as to how to became a Certified Brain Injury Specialist!
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